This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Radhesh Mahankali.
A 27 Year old male painter by occupation came to GM OPD with chief complaints of lower backpain since 1 week
HOPI:
Patient was apparently asymptomatic 3 months ago then he developed fever(low grade) continuous in nature and increased during night for 3 days for which he was treated by an RMP and was releived on medication. He was diagnosed by Hypertension 2 months back by the same RMP and was referred to an hospital where he was given medication for hypertension.
He then developed back pain since 1 week which is diffuse, non radiating, aggravated on prolonged sitting and relieved on rest.
PAST HISTORY:
K/c/o HTN since 2 months.
N/k/c/o DM, Asthma, TB, epilepsy, CVD, etc.
PERSONAL HISTORY:
Diet: mixed.
Appetite: Normal
Sleep: Adequate
Bladder: Normal
Bowel: Normal
Addictions: None
FAMILY HISTORY:
Not significant.
VITALS:
Temperature: Afebrile.
PR: 780bpm.
RR: 19cpm.
BP: 140/80 mm hg.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative, well oriented to time place and person.
No pallor.
No icterus.
No cyanosis.
No lymphadenopathy.
No Clubbing.
No Pedal edema.
CVS EXAMINATION:
S1&S2 heard.
No murmurs heard.
RESPIRATORY SYSTEM EXAMINATION:
Normal vescicular breath sounds are heard.
P/A: SOFT AND NON TENDER.
CNS: NO FOCAL NEUROLOGICAL DEFICITS.
INVESTIGATIONS:
Chronic kidney failure with hypertension(since 2 months).
TREATMENT:
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